Federico Nicoli

The development of clinical ethics in Italy and the birth of the “Document of Trento”

The Italian debate about the role of clinical ethics and ethics consultation has brought about the need to create a working group of Healthcare Ethics Consultation. The group began to take shape and to be organized in 2010; its activities are largely directed to share experiences, to analyze this field and to develop a professional profile of the clinical ethicist recognized throughout the nation. The working group of Clinical Ethics and Healthcare Ethics Consultation was born from some meetings and the group started to draft a Document about Clinical Ethics Consultation in Healthcare in Rome (June 2013). The Document was approved in Trento at the Kessler Foundation (October 2013) and undersigned by more than 200 people. The newborn document was called “The Document of Trento”: it is the first Italian document regarding clinical ethics consultation.

Donation After Circulatory Death: When Withdrawing Life-Sustaining Treatments Is Ethically Acceptable

The possibility to determine death based on cardiocirculatory criteria in controlled cases, namely when there is a request to withhold treatment-or, more frequently, withdraw it-specifically recalls the recent Italian law on advance treatment directives and leaves the following question unanswered: Under what conditions is the patients request legally and ethically acceptable? We present three ethical proportionality criteria for supporting physicians decision-making facing patients requests of treatment withdrawal, namely: 1. irreversible pathology with an ominous and worsening prognosis; 2. within an evaluation considering both clinical data and the patients history; and 3. facing burdens that are no longer bearable. We finally argue that reflection over controlled donor may be a model for giving medicine the chance to responsibly deal with broader end-of-life issues.

Domestic Use of the Exoskeleton for Gait Training in Patients with Spinal Cord Injuries: Ethical Dilemmas in Clinical Practice

In this paper, as in our previous works1 we evaluate some ethical questions about the domestic use of the robotic exoskeleton (ReWalk Robotics, Marlborough, MA, USA) (Esquenazi et al., 2012; Asselin et al., 2016) for gait assistance in people affected by a Spinal Cord Injury (SCI) (National spinal cord injury statistical center, 2010; Scivoletto et al., 2011). This device is presently FDA and EC market approved and it is now available in two different versions, one for hospital training and one for home-based use. The latter can be provided to the patient when a sufficient level of competence has been reached after special training. This work focuses on this second version of the ReWalk, since it was designed exclusively for domestic use. Ethical concerns may arise because financial coverage of the home ReWalk version is still under debate for most patients; it depends mainly on personal resources in so far as home delivery is not supported by common and shared International Provisional rules. In addition, in SCI patients the long term global consequences for health are marked by an increased risk of cardiovascular and metabolic diseases, while the paretic limbs may have a high risk of osteoporosis, skin lesions and deep venous thrombosis. Bowel constipation and pelvic floor impairment are other negative effects of SCI. Patents with SCI, their relatives, and their health care providers frequently classify the recovery of the ability to walk as a high priority, even where great effort has been made to alleviate the aforementioned consequences (American Spinal Cord Injury Association, 1982; Nene et al., 1996). To counteract these negative effects, Gait Retraining Programs have been operating for many years in order to exploit body-weight-supported gait on a treadmill (Sale et al., 2012), dynamic orthoses based upon passive mechanical hip-knee-ankle-foot orthoses (H-KAFO) which enable patients with SCI to ambulate over ground (Massucci et al., 1998) and/or similar synergic actions of Functional Electrical Stimulation (FES) with synchronized activation according to the different phases of the gait cycle (Nene and Patrick, 1990). Unfortunately, this type of treatment only results in obtaining a very slow gait speed with a high fatigue component.

Exoskeleton for Gait Training in Spinal Cord Injured People: Clinical Analysis and Ethical Dilemmas

According to recent epidemiological surveys 2.5 millions of people affected by a Spinal Cord Injury (SCI) are experiencing a variable degree of disability.

Medical Involvement in Acts of Torture or Degrading Treatment of Human Beings: Forensic and Medical Reflections

The following chapter condenses the reflections about the legitimacy of torture, a theme that the authors hope to contribute to in the opening of a debate on this important issue for the future of medicine and for the goals that medicine sets for itself in our time. The topic of this article is relevant to the debate exacerbated by the tragic events of 2001. In the case of capture of terrorists in possession of information regarding imminent attacks, is it permissible to subject them to torture? In what situations and under what conditions is it possible? We will report on the requirements of the critics of the international ban and the justifications for their arguments. We will present the criticisms of those who defend the maintenance of the prohibition of torture. Similarly we will discuss the positions of doctors who are favorable and adverse to participation in procedures of torture.

P-123 The psychology and the clinical ethics consultations: Different fields in the palliative care-hospice unit

Background To which different questions and needs does the role of the psychologist and the clinical ethicist attempt to reply in a Hospice – Palliative Care clinical setting? This contribution intends to investigate the contact and divergence points between the psychological intervention and the ethical consultation, starting from an analysis of the different competences and evaluating the aspects of a possible convergence, in a Hospice – Palliative Care Unit. Methods A review of the existing literature and a presentation of the clinical cases occurred in a Palliative Care – Hospice Units were performed. Results These two figures can improve the quality of the therapeutic intervention. They can work related in a different and complementary way, responding to different but essential questions and needs for a high quality of care. Discussion The different methods are compared to provide a good answer to specific issues related to the end of life. The psychological intervention is primarily oriented to understand which are the most appropriate actions to create the conditions to control the fear of death. Regarding the ethics consultation, the most relevant aspect concerns the research of a method to analyse the choices in relation to the end of life, crossing the monitored fear of the death. Conclusion The presence of both the professionals is considered necessary during the patient’s care in the Palliative care – Hospice Unit. Moreover, the two disciplines seem to be able to coexist and to complement each other and with other subjects of the healthcare team.